Provider Demographics
NPI:1437209426
Name:HEINTZELMAN, MARK E (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:HEINTZELMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8050 HOSBROOK RD
Mailing Address - Street 2:SUITE 402
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-2994
Mailing Address - Country:US
Mailing Address - Phone:513-794-0083
Mailing Address - Fax:513-792-3652
Practice Address - Street 1:8050 HOSBROOK RD
Practice Address - Street 2:SUITE 402
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-2994
Practice Address - Country:US
Practice Address - Phone:513-794-0083
Practice Address - Fax:513-792-3652
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3577103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH31-1210119OtherTAX IDENTIFICATION NUMBER
OH31-1210119OtherTAX IDENTIFICATION NUMBER